Page 135 - Journal of Special Operations Medicine - Fall 2017

hypoxia, hypocarbia or hypercarbia, hypoglycemia, and signs measurement of ONSD take priority over a neurologic
of elevated intracranial pressure (ICP) is essential. examination, and all results must be considered in the
context of the neurologic examination and overall pa-
Telemedicine – Management of TBI is complex. Establish tient status. See Appendix B for further details on using
a telemedicine consultation as soon as possible. ultrasound to obtain and interpret ONSDs.

Neurologic Assessment ONSD should NOT be attempted in any patient who

➤ ➤ Goal: Rapidly identify the clinical signs and symptoms of has sustained an open globe injury where any pressure on
TBI and associated traumatic injuries and assess TBI sever- the globe is contraindicated. As many as 30% of head inju-
ity. Track the progression of brain injury over time and be ries in combat may also have an eye injury. 6
vigilant for the early signs of rising ICP: worsening head-
ache, focal neurologic deficits and declining neurologic Monitoring
examination.
■ ➤ Primary survey: Perform a rapid trauma survey to assess ➤ ➤ Goal: Prevent secondary brain injury by maintaining ad-
all injuries. Determine and record the Glasgow Coma equate oxygenation and ventilation, avoiding hypotension,
Scale (GCS) score (Table 1). Assess pupils and motor observing for signs and symptoms of elevated ICP, and
function in all four extremities. trending the response to resuscitation. Detect changes in
■ ➤ Secondary survey: After stabilizing any immediate life- vital signs and neurologic examination as early as possible.
threatening injuries, assess for TBI red flags that may ■ ➤ Best: Portable monitor providing continuous vital-signs
indicate moderate to severe head injury (Table 2), and display, Foley catheter to monitor urine output. If an
perform an initial detailed neurologic examination. See advanced airway is in place, monitor end-tidal carbon
Appendix A for further details on performing a neu- dioxide CO (Etco ) with capnography. Check pupillary
2
2
rologic examination. Annotate findings on the PFC response and GCS score every hour. Document vital
flowsheet. signs, GCS, and urine output on the PFC Casualty Card
4
■ ➤ TBI severity classification using the GCS score : available at https://prolongedfieldcare.org.
Mild: 13–15 ■ ➤ Minimum: Blood pressure cuff, stethoscope, pulse ox-
Moderate: 9–12 imeter, method to monitor urine output. If an advanced
Severe: 3–8 airway is in place, monitor Etco with capnometer.
2
Check pupillary response and GCS as often as possible.
Table 1 Glasgow Coma Scale Document vital signs, GCS score, and urine output on
Eye Opening Verbal Response Motor Response the PFC Casualty Card available at https://prolonged
4 – Spontaneous 5 – Oriented 6 – Obeys commands fieldcare.org.
3 – To verbal 4 – Confused 5 – Localizes to painful ■ ➤ Assessment and Monitoring Notes
command 3 – Inappropriate stimuli ➤ o Perform an initial assessment according to TCCC/
2 – To painful words 4 – Withdraws from pain MARCH (Massive hemorrhage, Airway, Respira tions,
stimuli 2 – Incomprehensible 3 – Flexion to pain
1 – No response sounds 2 – Extension to pain Circulation, Head injury/Hypothermia) algorithms.
1 – No response 1 – No response Severe head injury is associated with additional
trauma in 60% of patients. 7
➤ o If ONSD is used to evaluate for increased ICP and
Table 2 Features Indicative of Moderate to Severe Head Injury response of ICP to interventions, repeated ultra-
Red Flags sound examinations should be performed if there is
Witnessed loss of consciousness any change in neurologic examination and at regular
Two or more blast exposures within 72 hours intervals (30 minutes) after performing ICP-lowering
Unusual behavior or combative interventions.
Unequal pupils ➤ o When possible, a pocket ophthalmoscope can be
Seizures used to assess for the presence or absence of spon-
Repeated vomiting taneous venous pulsations (SVPs). SVPs are only
Double vision or loss of vision present when ICP is normal. Visualization of SVPs
Worsening headache can reassure the provider that ICP is not critically
elevated. See Appendix C for additional information
8
Weakness on one side of the body on the rapid assessment of SVPs.
Cannot recognize people or disoriented to place ➤ o Consider early C-spine immobilization. The inci-
Abnormal speech dence of concomitant brain and spinal cord injury
in trauma ranges from 25% to 60%, with motor ve-
■ ➤ Neurologic Assessment Note: An emerging technology hicle crashes and falls having the highest incidence
9
that can be considered as an adjunct to neurologic as- of co-occurence. Ensure the cervical collar does not
sessment is ultrasound measurement of optic nerve compress the jugular veins in the neck, because that
sheath diameter (ONSD). If the patient is unconscious could worsen ICP.
(i.e., does not follow commands or open eyes spontane- ➤ o The neurologic examination is essential to identify de-
ously), measure a baseline ONSD. There is no definite terioration in a TBI patient. Treat for elevated ICP for
diameter that is diagnostic of increased ICP; however, any deterioration in neurologic examination findings.
an ONSD >5.2mm, especially if it increases over time, ➤ o Pain medication and sedation are usually required
may indicate elevated ICP. In no circumstance should for TBI patients; however, these medications also
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Guideline: TBI Management in PFC | 131